Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse

Transcription

1 British Journal of Obstetrics and Gynaecology June 2001, Vol. 108, pp. 629±633 Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse Elad Leron a, Stuart L. Stanton b, * Objective To study the ongoing results of sacrohysteropexy with Te on mesh for treatment of uterovaginal prolapse in women who desire to preserve their uterus. Design Prospective observational study. Setting Tertiary referral urogynaecology unit. Participants Thirteen consecutive women with uterovaginal prolapse wishing to retain their uterus operated on by one surgeon. Surgical method Sacrohysteropexy with Te on mesh attached to the uterine isthmus and to the anterior longitudinal ligament of the rst or second sacral vertebra in a tension-free fashion. Main outcome measures Subjective and objective cure of uterine prolapse and operative and post-operative complications. Results The mean age of the women was 38 years (range 27±60). Eight women were multiparous. Twelve women had second degree uterine prolapse and one woman had third degree of uterine prolapse. Mesh was extended to correct a cystocele in one woman and a rectocele in three women. In four women colposuspension was performed at the same time. There were no intra- and post-operative complications. The mean follow up time was 16 months (range 4±49). At follow up only one woman had a rst degree uterine prolapse. A total of seven women (53.8%) reported constipation which had been experienced pre-operatively by four women (30.8%). Conclusions We consider the sacrohysteropexy with Te on mesh a safe, effective and durable surgical procedure for the management of uterovaginal prolapse in young women and those who desire to retain their uterus. INTRODUCTION The rst reports of genital prolapse are in the Ebers papyrus dated 1500 BC. The treatment consisted of smearing the prolapse with a mixture of honey and then replacing it. In 400 BC Hippocrates described treatment of uterine prolapse by tying the patient upside-down and shaking her violently, or the reduction of the uterine prolapse by introducing a half pomegranate soaked in wine into the vagina. Donald of Manchester and his assistant Fothergill described the rst surgical methods of treatment in This was later called the Manchester operation 1. a Department of Obstetrics and Gynaecology, Soroka Medical Centre, Ben-Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel b Pelvic Reconstruction and Urogynaecology unit, Department of Obstetrics and Gynaecology, St. George's Hospital Medical School, University of London, UK * Corresponding,: Professor S. L. Stanton, Pelvic Reconstruction and Urogynaecology unit, Department of Obstetrics and Gynaecology, St. George's Hospital Medical School, Lanesborough Wing, Cranmer Terrace, London, SW17 0RE. q RCOG 2001 British Journal of Obstetrics and Gynaecology PII: S (00) The successful surgical management of uterine prolapse with retention of the uterus is a surgical challenge. The aims of pelvic reconstructive procedures are to correct prolapse, maintain urinary and faecal continence, and preserve coital function. Operative procedures for uterine prolapse have included xation of the uterine vault to the undersurface of the abdominal wall (ventral xation/hysteropexy), transvaginal uterosacral ligament xation to the sacrospinous ligament 2, and laparoscopic uterine suspension by suturing round ligaments to the rectus sheath 3. Arthure and Savage 4 were the rst to describe attachment of the prolapsed uterus to the sacrum using an abdominal approach. The indication for surgical correction of uterine prolapse is failure of conservative treatment in a healthy young nulliparous woman or a woman with congenital anomaly (e.g. bladder exstrophy), or where child-bearing is incomplete, and nally where a patient with a signi cant uterine prolapse refuses hysterectomy and wishes to retain her uterus. The surgical management of symptomatic uterovaginal prolapse in a young woman creates a special problem and challenge since it is desirable to retain the child bearing potential. In these circumstance abdominal sacrohysteropexy is indicated. We report the results of our use of sacrohysteropexy with Te on mesh in 13 women with signi cant uterine prolapse.

2 630 E. LERON & S. L. STANTON METHODS Thirteen consecutive women who wished to retain their uteri presented with signi cant uterine prolapse and were evaluated by means of structured and standardised questionnaire, physical examination and appropriate urodynamic studies (pre-operative and post-operative subtracted cystometry). All de nitions conform to the International Continence Society (ICS) Standards 5. Prolapse was de ned as rst degree when it reached about 1 cm above the introitus, as second degree when the presenting part was at the introitus, and third degree when it was beyond the introitus. In order to predict lower urinary tract function postoperatively and the possible need to add an operative procedure should urethral sphincter incompetence be diagnosed, we performed urodynamic studies with the prolapse reduced. When urethral sphincter incompetence was diagnosed a colposuspension was performed. Thirteen consecutive women, who underwent sacrohysteropexy between February 1993 and March 1999 participated in the study. Their mean age was 38.4 years (range 27-60). Five women were nulliparous and eight were multiparous. Twelve had 2 degree and one had 3 degree uterine descent. Two women wished to retain the uterus because it was an integral part of themselves and of the sensation of wholeness as a woman. The remainder wished to preserve their fertility. Operative technique The sacrohysteropexy was performed under general or spinal anaesthesia. All cases had cephradine 1g intramuscularly and metronidazole 1g per rectum given pre-operatively. The patient was placed in a supine Trendelenburg position and a low transverse (Pfannenstiel) or a vertical incision was performed (the latter is chosen for better access if the patient was short and obese). When a colposuspension was required, it was performed rst. The bladder was catheterised and after opening the peritoneal cavity an abdominal and pelvic exploration were performed. The intestines were packed with a moistened abdominal pack and a self-retaining Turner± Warwick ring retractor inserted. Uterine-holding forceps elevated the uterus. A sterile piece of Te on mesh (Bard Europe, London, UK) 20 cm x 4 cm was bifurcated to produce a `Y' shaped or trousered graft. Each broad ligament at the level of the cervico-uterine junction was perforated through an avascular area using diathermy and scissor dissection. A limb of the trouser mesh was introduced through this lumen. The vesico-uterine peritoneum was incised and the bladder dissected distally for a distance of 1-2cm, to allow the limb of the mesh to be sutured using a No. 1 polybutylate coated polyethylene suture on a `J' needle (Ethibond, Ethicon Limited, Edinburgh, UK) to the anterior cervico-uterine junction. This was repeated on the contralateral side. The mesh was then sutured to the posterior cervico-uterine junction. The arms of the mesh were not sutured together anterior to the cervico-uterine junction to avoid complete encirclement of the uterine isthmus and to allow the expansion of the lower uterine segment should pregnancy occur (Fig. 1). Next the peritoneum over the anterior surface of sacral vertebra 1 or 2 was incised and this was continued downwards to create 2 peritoneal aps along the anterior ligament and oor of the pelvis. The anterior longitudinal ligament was carefully dissected clear of blood vessels using sharp dissection and a diathermy. The mesh was allowed to lie without tension on the pelvic oor and in the hollow of the sacrum and sutured using Ethibond 1 sutures to the anterior longitudinal ligament and peritonealised as far as possible using the peritoneal aps. The utero-vesical peritoneum was closed. If there was a rectocele the rectum was dissected free from the posterior wall of the vagina and a further piece of mesh attached to the perineal body, side of the posterior vaginal wall and then joined to the posterior cervico-uterine junction. An intraperitoneal drain was inserted and if a colposuspension was performed, a suprapubic catheter was used. Te on mesh is a foreign substance and it was important take all precautions against any possibility of infection. All sacrohysteropexies were performed by the same surgeon (S.L.S.) and prophylactic heparin 5000 units was given subcutaneously twice daily until the woman was fully mobile. The intraperitoneal drain (if present) was removed within 24 hours of surgery. If a colposuspension was performed, a suprapubic catheter regime was followed. Fig. 1. Sagittal section of the pelvis showing sacrohysteropexy mesh in place between the cervical uterine junction and anterior longitudinal ligament over the rst sacral vertebra.

3 Table 1. Pre- and post-operative symptoms. Values are given as n (%), mean [SD]. SACROHYSTEROPEXY WITH SYNTHETIC MESH FOR PROLAPSE 631 Symptoms Pre-operative Post-operative P Stress incontinence mild±3/13 (23) mild±3/13 (23) 50 [17.7] moderate 3/13 (23) moderate±none Urgency mild±3/13 (23) mild±2/13 (15.3) 62.5 [17.1] moderate±4/13 (31) moderate±1/13 (7.7) Urge incontinence mild±2/13 (15.3 mild±1/13 (7.7) 50 [17.7] moderate±2/13 (15.3) moderate±1/13 (7.7) Prolapse symptoms moderate±8/13 (61.5) mild±2/13 (15.3) 87.5 [11.7] severe±5/13 (38.5) moderate±1/13 (7.7) Constipation mild±4/13 (30.8) mild±4/13 (30.8) moderate±1/13 (7.7) severe±2/13 (15.3) Dyspareunia mild±2/13 (15.3) mild±3/13 (23) 28.6 [17.1] moderate±2/13 (15.3) How has the operation changed your life? - much better±4/13 (30.8) - slightly better±3/13 (23) - unchanged±2/13 (15.3) - unclear±4/13 (30.8) Statistical analysis This was performed on the paired observation for each woman, before and after the operation. For a given symptom the proportion of women who improved was calculated, where improvement was de ned as reduced severity of the symptom reported after the operation as compared with before the operation. The estimated proportion is given with a 95% con dence interval. RESULTS The mean follow up time was 15.6 months (range 4-49). Pre-operative second-degree uterine prolapse was diagnosed in 12 women, and one woman had third degree uterine prolapse. Anterior mesh extension to correct cystocele was performed in one woman and posterior mesh extension to the perineal body to correct rectocele were performed in three women. Concomitant surgeries were: colposuspension (4), posterior repair (2), uterosacral plication (2), tubal ligation (1), and external anal sphincter repair with anterior levatorplasty (1). The mean estimated blood loss was 271mL (range ). Blood loss.350ml occurred where a sacrohysteropexy was performed together with a colposuspension. No intraoperative or post-operative complications occurred. The mean hospital stay was 4.6 days (range 4-6). All patients were sexually active pre-operatively and remained so post-operatively. No pregnancies ensued during the follow up period as none of the patients wished to conceive at that time. Therefore, no attempts were made to assist in fertility. Pre-operative and post-operative symptoms are given in Table 1. Symptoms were graded as mild when experienced not more than once a week, moderate when they occurred several times a week but not every day, and severe when they occurred every day. Dyspareunia and prolapse symptoms were described using a score between 1 to 5, where 1 denotes mild and 5 denotes severe. The three women were cured of their stress incontinence by colposuspension: 1 woman reported no change. Urgency and urge incontinence and dyspareunia were improved and prolapse was markedly improved. More patients complained of constipation following surgery. More than half the patients felt the operation had improved their life (Table 1). Clinical examination post-operatively showed that cystourethrocele and rectocele were improved. Uterine descent was detected in only one patient ( rst degree). No abnormal pelvic tenderness was noted. DISCUSSION The management of uterovaginal prolapse in young women and those who wish to retain their uterus poses a challenge and dilemma for the reconstructive pelvic surgeon. Most reconstructive procedures are designed for older women in whom fertility, uterine preservation and sometime coital function are not important factors. In the younger age group, the surgical aims are to correct the prolapse, preserve a functioning vagina and retain childbearing potential. Several approaches have been advocated for the management of uterine prolapse in young women or those who desire to retain their uteri: 1. vaginal shortening of the uterosacral and cardinal ligaments, usually with cervical amputation (Manchester procedure); 2. xation of the pelvic structures to the anterior abdominal wall; 3. transvaginal sacrospinous xation; 4 anchoring of the cervix/uterus and/or vaginal walls to the sacral promontory±sacrohysteropexy with mesh. The Manchester operation had signi cant deleterious effect

4 632 E. LERON & S. L. STANTON on fertility 6 ; conception occurred only in 10% to 20% of patients. Complications included dyspareunia, dysmenorrhea, and recurrent uterine prolapse and enterocele 7. Several authors have endeavoured to cure uterine prolapse with xation to the anterior abdominal wall. Synthetic material, such as Dacron tape or strips of external oblique aponeurosis, were employed to suspend the uterus with disappointing results 2,3. With this type of procedure, the signi cant change in the normal vaginal axis causes abdominal pressure to be transmitted to the cul-de-sac, thereby potentiating the possibility of subsequent enterocele formation. The advantages of transvaginal sacrospinous xation include a reduction in postoperative pain, as the procedure is performed vaginally, and maintenance of the normal vaginal axis reducing the potential of enterocele formation 2. On the other hand, the proximity of the sacrospinous ligament to the sciatic nerve and pudendal vessels and nerves may cause significant buttock and leg pain and haemorrhage. Kovac and Cruikshank 8 performed 19 sacrospinous uterosacral ligament xations in women with symptomatic uterovaginal prolapse who desired either uterine preservation or future child-bearing ability. Five of them have since been delivered vaginally and normal anatomic restoration was accomplished in all but one woman. In one case, an accidental opening was made into the rectum 8. Several authors 9±14 have recommended the abdominal approach. We believe that this approach yields a durable and satisfactory anatomical functional result. All our patients have maintained good anatomical support with functional and normal vaginal axis for the follow up period. None of them have yet conceived. Post-operative prolapse symptoms and vaginal examination parameter improvement rates were 87.5% and 71% to 100%, respectively, although only 54% deemed themselves as much better or slightly better in responding to the question of how has the operation changed your life? The other 46% were unchanged/unclear regarding this question. Van Lindert et al. 12 performed abdominal-retroperitoneal sacral genito-colpopexy using the expanded polytetra uoroethylene soft tissue patch for repair of genito-vaginal prolapse in 61 women with a mean of 32 months of follow up, with 95% classi ed as successfully treated. Eight of their patients underwent anterior and posterior colposacropexy with preservation of the uterus. Banu 13 reported on 19 women (age years) who were treated with abdominal sacrohysteropexy with Mersilene tape. The follow up period was three to ve years, and no recurrence was noted. Costantini et al. 14 reported on seven women treated by hysterocolposacropexy preserving the uterus using Gore Tex mesh with satisfactory results, although in three of them rst-degree cystoceles recurred. Complications are uncommon, and even less than the range of what is expected for women undergoing complex abdominal/pelvic surgery with placement of a foreign substance 12. Post-operative deep vein thrombosis and thromboembolism were rarely reported, and preventive measures such as the perioperative mini-dose of heparin, early ambulation and compression stocking should be applied. Minor complications such as urinary retention, voiding dif culties, micturitional urgency dysuria and dysmenorrhea, have been reported and resolved with conservative management. One case of bladder instability was reported as well. No rectal compression or ureteric injury have been reported 13,14, and in our series of sacrohysteropexies, no intra- or post-operative complications occurred. The use of a foreign body mesh means that there is always a theoretical risk of erosion to an adjacent intraperitoneal structure or adhesion of bowel to it with development of symptoms and signs of acute or chronic obstruction. Patients should be cautioned about this potential complication. In our series no erosion, infection or rejection of the Te on mesh have occurred, and we continue to use Te on as the preferred material for sacrocolpo/hysteropexies. CONCLUSION We conclude that in women with uterovaginal prolapse who wish to retain their uterus, durable anatomic restoration and normal vaginal axis are ef ciently achieved by an abdominal sacrohysteropexy with Te on mesh. This procedure can permanently eliminate the prolapse symptoms without painful or rigid vaginal scarring. References 1. Loret de Mola JR, Carpenter SE. Management of genital prolapse in neonates and young women. Obstet Gynecol Surv 1996;51:253± Richardson DA, Scotti RJ, Ostergard DR. Surgical management of uterine prolapse in young women. J Reprod Med 1989;34:388± O'Brien PM, Ibrahim J. Failure of laparoscopic uterine suspension to provide a lasting cure for uterovaginal prolapse. Br J Obstet Gynaecol 1994;101:707± Arthure HE, Savage D. Uterine prolapse and prolapse of the vaginal vault treated by sacral hysteropexy. J Obstet Gynaecol Br Emp 1957;64:355± Abrams P, Blaivas JG, Stanton SL, Anderson JT. The standardization of terminology of lower urinary tract function. Br J Obstet Gynaecol 1990;97:1± O'Leary JA, O'Leary JL. The extended Manchester operation. Am J Obstet Gynecol 1970;107:546± Tipton RH, Atkin PF. Uterine disease after the Manchester repair operation. J Obstet Gynaecol Br Comnwlth 1970;77:852± Kovac SR, Cruikshank SH. Successful pregnancies and vaginal deliveries after sacrospinous uterosacral xation in ve of nineteen patients. Am J Obstet Gynecol 1993;168:1778± Aboulghar MA, El Kateb Y. Treatment of uterine prolapse in young women: sacral cervicopexy by polyvinyl alcohol sponge. J Egypt Med Assoc 1978;61:127± Dewhurst J, Toplis PJ, Shepherd JH. Ivalon sponge hystersacropexy for genital prolapse in patients with bladder exstrophy. Br J Obstet Gynaecol 1980;87:67±69.

5 SACROHYSTEROPEXY WITH SYNTHETIC MESH FOR PROLAPSE Dastur B, Gurubaxani G, Palnitkar SS. Shirodkar sling operation in the treatment of genital prolapse. J Obstet Gynaecol Br Comnwlth 1967;74:125± Van Lindert ACM, Groenendijk AG, Scholten PC, Heintz APM. Surgical support suspension of genital prolapse, including preservation of the uterus, using the Gore Tex soft tissue patch (A preliminary report). Eur J Obstet Gynaecol Reprod Biol 1993;50:133± Banu LF. Synthetic sling for genital prolapse in young women. Int J Gynaecol Obstet 1997;57:57± Costantini E, Lombi R, Micheli C, Parziani S, Porena M. Colposacropexy with Gore-Tex mesh in marked vaginal and uterovaginal prolapse. Eur Urol 1998;34:111±117. Accepted 21 February 2001